Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.101 n.8 Cape Town Aug. 2011

Over 46% of the country's population lives in rural areas where just 2.9% of local medical graduates end up annually.

With many medical schools boldly piloting on-site clinical training in vastly underserved rural areas, the top generalist educators among South Africa's eight medical campuses last month agreed to urgently petition government for expanded rural teaching platforms.

Over 46% of the country's population lives in rural areas where just 2.9% of local medical graduates end up annually, the massive unmet service delivery crying out for government intervention - and the academics want to suggest pragmatic solutions. The group, consisting of top rural health training advocates at the universities of the Witwatersrand, Pretoria, Western Cape, Stellenbosch, Cape Town and Walter Sisulu University (Mthatha), held a rural clinical schools workshop at UCT's Sports Science Academy on 23 June this year. Facilitated by Benguela Health, it followed an Atlantic Philanthropies-funded tour to South Eastern Australia (Gippsland and Victoria) by several participants to observe best practice in expanding rural health training facilities.

The timing of the workshop petition, to be presented to the South African Committee of Deans this October, after which a compelling best-evidence set of recommendations for increased rural clinical schools support will go to the Health and Higher Education ministries, could not be better. Health Minister Dr Aaron Motsoaledi is diligently setting up new district maternal and child health care teams, having publicly vowed to triple the country's 1 200 annual MB ChB graduate output in order to make some dent in the apparently intractable human resource (HR) crisis. His weapons of choice so far are a ninth medical school in Limpopo, rebuilding and expanding Medunsa as a stand-alone institution, asking the deans of all medical schools to find ways to increase their intakes and funding new infrastructure at four tertiary hospitals and their medical schools (George Mukhari, Chris Hani Baragwanath, King Edward VIII and Nelson Mandela Academic Hospitals).

We'll help you staff and sustain your programmes

The new rural clinical schools petition, backed by the country's top medical academics, will consist of a pragmatic plan based on best evidence globally. The group believes higher-intake rural clinical schools set in underserved communities will help address Motsoaledi's overall problem by producing greater numbers of appropriately trained doctors more likely to stay in the struggling rural health sector. Overall, the public sector scrapes by with just 30% of the country's doctors, serving 85% of the population. The overwhelming local rural HR need is best illustrated by the following data: the most rural province, North West, has 1.9 doctors and 0.3 specialists to 10 000 people and the next most rural, Limpopo, has 2.7 doctors and 0.2 specialists per 10 000 inhabitants. Country-wide the ratio is 2.9 doctors and 1.1 specialists per 10 000 citizens. So far, state strategies to attract health care professionals to underserved areas (i.e. rural and special skills allowances, foreign recruitment) have met with limited success. Appropriately trained and skilled doctors and nurses with the durability and commitment required by sustainable rural health care are as rare as hen's teeth - in spite of several ongoing complementary recruitment initiatives by the Rural Doctors Association of South Africa (RUDASA) and other NGOs which outstrip government efficacy. Currently most rural practising health care professionals are recruited in batches overseas (fraught, so-called government-to-government agreements), are urban-raised and trained locals (the majority being community service officers in compulsory state service), or come from diligent NGO recruitment. The majority have limited long-term investment in, or commitment to, the unfamiliar and predictably harsh rigours of rural health care life.

The suggested strategy by the country's top rural and underserved community-oriented teachers' centres on the growing body of evidence globally that career choice is strongly influenced by where and how a student is trained - and that those with rural roots are more likely to return to a rural setting. Successful local pilot programmes so far have medical schools designing their curricula around a significant portion of training at rural sites, with the most successful setting up rural clinical schools where the most needy populations are. Professor Dan Ncayiyana of Benguela Health, an innovative pioneer of 'problem-based learning' within communities in the Eastern Cape during his tenure at Walter Sisulu University (then Unitra), led the South African delegation to Monash and Flinders University in Australia. He said he returned more convinced than ever that rural clinical training was 'the way to go' for South Africa, for three main reasons. It enabled training of health professionals to attend to the health needs and circumstances of neglected communities by equipping and motivating them to serve. It dramatically lifted the quality of care in those communities and contributed to an expanded clinical training platform - which allowed for a bigger intake of students. He quipped that one needed to 'look no further' than his home town of Durban (the only place where black people could study medicine during the earlier apartheid days) for evidence that medical professionals returned to their training grounds to practise. 'It's the most diverse medical community imaginable - so if you want to produce a crop of doctors who stay rural, you must recruit and train them in rural areas,' he added.

Professor Jannie Hugo, the leading local developer of mid-level medical workers, Family Medicine Chief at the University of Pretoria and a top protagonist of community-oriented primary care, said he would 'do one simple thing' were he the national health minister. 'I would spend all the extra education money that comes free (of 'normal' budget) in areas of (health care) need'. He warned that the focus should not just be on the rural selection of medical training candidates, but on 'value of service with an emphasis on existing inequities'. The workshop agreed that underserved areas should be the target of expanded on-site, multidisciplinary training interventions, not just necessarily rural areas.

Rural-schooled doctors better leaders/team players

There was consensus that rural-schooled students regularly outperformed their urban trained colleagues in terms of enhanced team and leadership skills. The workshop also agreed that the emphasis should not just be on medical professionals but on 'inter-professional health care training' in underserved areas in order to develop teams appropriate to existing needs. Hugo said a pivotal aim should be to train people for task shifting in order to address the HR crisis, adding: 'Health-wise this country is in a state of war. During the war years, the Rolls Royce factories were making tanks. I regard South Africa in the same light. We need to create the types of people who fight the war, maybe a guerilla war. While I don't like the war metaphor, I'm certainly not interested in creating Mercedes' for exportation.'

Dr Elma de Vries, a former chairperson of RUDASA and a senior lecturer in Family Medicine at UCT, reminded her colleagues of the World Health Organization (WHO)'s policy recommendations on 'increasing access to health workers in remote and rural areas through improved retention'. These included locating health professions schools, campuses and formal medical residency programmes outside of capitals and other major cities because graduates of these schools and programmes were more likely to work in rural areas.

The South African delegation to Australia found that effective rural clinical training:

 took place in areas where there was a sound district health service with appropriate infrastructure and amenities (including primary and secondary schools)

 was in group general practices accredited for training

 had political will and support

 produced committed health practitioners who understood their role in workforce planning and support

 contributed to improved quality of care wherever it was located

 offered opportunities for multi-professional training

 created synergy between programmes and a sharing of educational resources

 worked best with a platform consisting of a regional hospital, group general practices and primary level clinics

 enabled collaboration between different universities sharing the same teaching platform

 was 'essential and feasible in South Africa'.

Professor Robyn Hill, who helped set up the graduate entry rural medical school in Gippsland for Monash University (and guided the South African visitors) said much of their training was in depressed socio-economic former mining areas. She pioneered the hugely successful on-site training of first-year medical students by clinical nurse educators. 'We have pockets of really depressed, needy areas which pale in comparison to your country-wide needs, but our objectives are beautifully aligned to uplift communities who really take ownership of these projects,' she told Izindaba.

Professor Ncayiyana told the workshop that he 'did everything short of getting Julius Malema to lobby for us' in persuading the national health minister and his or various provincial health directors general to attend the Cape Town workshop. However, he was optimistic that once they eventually saw the full report, backed by the Committee of Deans, progress towards their mutual goals would accelerate.